If you are providing counseling on smoking and tobacco-use cessation during patient office visits, follow these guidelines to make sure you get paid accurately for it.
CHECK THE PAYOR’S POLICY
Not all medical policies are the same, so it is important to verify coverage prior to submitting the claim. Even though many payors follow Medicare, keep in mind not all do. Be sure to check with your local Medicare and commercial insurance for specific requirements.
E&M – Get Paid for Smoking & Tobacco Use Cessation Counseling
CPT CODE SELECTION
Review the CPT codes and take note of the code description. The codes for these services are time-based. Therefore, you must document the time in minutes spent on counseling the patient on smoking and tobacco use cessation.
99406 – Smoking and tobacco use cessation counseling visit, intermediate, greater than 3 minutes up to 10 minutes
99407 – intensive, greater than 10 minutes
DIAGNOSIS CODE SELECTION
Diagnosis codes that will meet medical necessity will vary by payor. Always check the patient’s insurance policy. Below are just a few examples of codes found in most policies:
F17.200 – Nicotine dependence, unspecified, uncomplicated (includes mild, moderate, severe tobacco use disorder)
F17.201 – Nicotine dependence, unspecified, in remission
F17.210 – Nicotine dependence, cigarettes, uncomplicated
F17.211 – Nicotine dependence, cigarettes, in remission
F17.220 – Nicotine dependence, chewing tobacco, uncomplicated
F17.221 – Nicotine dependence, chewing tobacco, in remission
F17.290 – Nicotine dependence, other tobacco product, uncomplicated
F17.291 – Nicotine dependence, other tobacco product, in remission
T65.214A – Toxic effect of chewing tobacco, undetermined
T65.224A – Toxic effect of tobacco cigarettes, undetermined
DOCUMENTATION – INCLUDE WHAT WAS DISCUSSED
The documentation in the medical record must support the codes assigned. Specifically, document what was discussed:
- The patient’s current tobacco use
- The patient’s desire or need to quit
- Identify the cessation technique(s) and resource(s) provided
- Estimated quit date
- Planned follow-up
- Include the time spent in minutes
Examples:
Insufficient documentation
“I counseled the patient to quit smoking, but the patient responded he wasn’t ready to quit at this time.”
Complete documentation
“The patient has atherosclerosis with an ulcer on the left toe but continues to smoke one pack of cigarettes per day. I spent 12 minutes counseling the patient on cessation techniques. She understands continuing to smoke could lead to unhealed ulcers, amputations and even death. The benefits of quitting were provided, and she agreed to give it a try. A goal was set to be smoke-free within the next six weeks. I will follow up in two weeks to check progress.”
BOTH E/M SERVICE AND SMOKING AND TOBACCO COUNSELING ON THE SAME DAY OF SERVICE
Medicare and most commercial payors will allow payment for a medically necessary E/M service on the same day as smoking and tobacco counseling. Both services can be documented on the same report, but it is imperative to separate the time spent in minutes for each service. When both are done on the same day, assign modifier 25 to the E/M service code to indicate it was a separately identifiable.
Example:
Total time spent on an established patient office visit was 20 minutes. Separately, 5 minutes was spent counseling on smoking cessation.
99213-25 – Office visit
99406 – Smoking cessation
LIMITATIONS
Medicare and certain payors will cover two attempts per year. Each attempt includes no more than four intermediate or intensive counseling sessions.
REIMBURSEMENT
2022 Medicare Physician Fee Schedule National Payment Amount
CPT Code Non-Facility Facility
99406 $15.57 $12.11
99407 $28.72 $25.61
Copayment/coinsurance as well as the deductible for 99406 and 99407 are now waived. The Medicare beneficiary has a zero-dollar out-of-pocket liability.
SUMMARY
- Check the specific payor’s policy to determine coverage and reimbursement
- Specify the time in minutes spent with the patient discussing tobacco-use cessation counseling
- Document what was discussed
- Current tobacco use
- Desire or need to quit
- Technique(s) and resource(s) provided
- Estimated quit date
- Planned follow-up
- When an E/M service is performed in addition to counseling for smoking and tobacco use cessation separate the time spent for each service
- When an E/M service and a smoking and tobacco counseling are done on the same day, assign modifier 25 to the E/M service code
References:
CPT 2022 Professional Edition
2022 ICD-10-CM
2022 Medicare Physician Fee Schedule
NGS Medicare Q. & A.
